S 1274 (2) APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING ELECTRICAL 1
PE' NO
'i'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1274
'BUILDING PROJECT IDFNTIFICATION,I, '
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ON RE5 I, w - R(A) w
OWIA'F.R:S NAME;: PHONE: COR IS N7 LIC LICN(l: N/C CONTROL
HIT GCrIFKV0IN- R: LIC N0 ADDRESS: Z9/a_ ❑
Nb N FRG 5 (`0N 2 rbS13'g1V*U N
CONNTACT. TI FEnIBRUNNPHONE: T BUILDINGPERMITINFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
HlS 9 ! $b00 —
LICENSED CON IRACIORSDECLARATION QTY "� ELECTRIC PERMIT FEE
I by fC that 1 d d p f chapter 9(unnmm g .- , _ .JOB DESCRIPTION
Aaz with$ i 7000) rDi 'xlon 3ofthc Basin ss and Ped,,wns Code,atdmy lice c RESIDENTIAL:
FSB in f......ceaad effect PERMI'I'ISSUANCE
WF- OSFDWL [I KITCHEN REMODEL
�UU Liccnsc Claes- Lic'N 'APPLIANCES-RESIDENT['IAI. ❑ADDfI'[ON O PLUMBING RETHIE
y�a] Datc Cenln¢lor
¢❑w 6.
AtCH ECTS IIECLA A'I N PANGLS ❑MULTI-UNIT ❑STRUCTURAL
zbzz Iunderstandm I e expubliceecuNs MODIFICATION
-Oz4O UP TO 200 AMPS El INTERIOR L1 CHIMNEY REPAIR
�r/F{,,; Lice cd Profuseianf 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
�hC � OW -BUILDER DECLARATION OVER IOOOAMPS O BATH REMODF.IAREPAIR ODEMOUTION
CC 1 hereby,Kin that mat treat the Contractors License Larlofoor The
O U Followla S Sion 3L5 eBusinces and Profession,Cade:An t tbrcopnt " ❑OTHF,R
iiXW� y g ravroa (. y ci y SIGNS ELECTRICAL
PJ W�h which requires v permit m wm,vun,idler,improve,demolish,or repair any�a u
�,..fid prior[ t 'Iso y tit Olua If I ht fl it d.t tc at - w\�PECIAL CIRCIII'DMISC.
:Fo0 to thrth dfirmament t thep 1mm fm C t t isL Law(Clmrye -
� d� (a,mmmmmg wiTSmtion p11IM1)ml Divixion3 oflhe Bae nese anJ Pmfcsnions Coder WE METER OIA'OLE INET. COMMERCIAL,
d y o y that he is cxempl therefrom and the tiuvis fur We alleged exemption Any violotian a15 �,s W - ❑NEW BLDG/ADDITION 0 DEMOLITION
m Section 703 L5 by tre epplicnnt for a permll,rapetstire applicnnue advllpenwtyd rp ,DEVICESTENANT
n more than flue hundred dollars($500), �- 0 IMPROV
p 0 FOOD SERVICE
^ � O I,as owner of the property,or my emNeyees with wageses thei"miccomp��.I
'sx n a o E%crR1c
will do Om work,and J�estrucwrcis net intended onhffereJl rwlc(Sca.7U14.Rosiness '
W,^3 m and Pmfe„ioa,Cale:The Contractors Lice v Law does not apply to ua owner of OUTCBI�S�S�B�IGHHS-FIXTURES
FF properly who builds or improves thermnt,and who docs such work himself or threagh �v✓
his own employees,provided that such in,pmvmncnts am not intended or nliered for � A RE91ky!1 LF It SQ IT
sale ll;howevim,hebuilding er improvement is sold within oneyear mfemagetimn,the _ "'� SQ.FT.FLOOR AREA 'Q FI'.
er-budder will have the h al linving that he did not build or improve for Fur- �; s \
1 or �'��
OsI,us owner or property,am exdnsivdy connecting with Ilcensnl contractors m N A )TAI
construct the in] t(See 7094 [lesions,and I'mme,,mrs Carl The C t t L - - ae"-
cerise L f t apply t f 1 p try n b -Id: improve,tl d QTY'. 'PL IN(i,PEli" .FEE
who tracts for such p 1 ,with a covti cted)I',va,diu. ant to the Contractors
'r 'KYpA"N. Y, kn. - -
License Law. PERMIT ISSUANCE. \\,
I am exempt under Sec. .B&P C lair Wie rennin ti���
AFTER-DRAIN&VENT-WATER EN) -�
Owv n pVALUATnnION
WORKER'S COMPCNSM ION DECLARATION HACK FLOW PROTGC'T.DEVICE P M L
I hcrehy afoul under peachy nraujer,rane er the h,llmwing dedamtlens: V
I have and will mnlnmin at Cutill of Consent to self-iasum lar Worker's Comil DRAINS-FLOOR,ROOF.AREA,COND. v BCONSTRUCI'ION
ten,as provided for by Section 3700 of the Labor Code.for the pafarnhance of the O Ip �.
Xk t heart fl permit d FIXTURES-PER[RAP 9
My Work 1 aborti Under,for
he k C e a' I . s I by Ssined
Ih and Illi (�yt',R�LL�t�
f the pct e of the work for lh'.remains ism ui. GAS EA.SYSTEM I INC,40UTLE'1'S IWIH I VI FVUI't I,jpito Al
F
a tectrr dl l y nmbc rc - .
'
Carrier. � Policy N,,:_ GAS CA.SVSTFM SYSTEM-OVER 1 '110F IMPION FROM WORKERS'
COMPENSATION INSURANCE GRHASEIINDUSTRL WAS I E INTERCEPTOR
6-
T'issectlounced not be completed ifthe Per°° munt is I anc hdred dol lues G 100) ., § HUILgiNC DIVI5IOr�1'HEB
GRGASE'I'RAP -
iPLANCHLCK P
or ces) EE .
I ready that in the perfournmeuafthe work for which this permit,,i...ed,I,left SEWER-SANITARY-STORM EA.200I?,
not chadoy any pemun In any manner vo as m beemoo subject w the Workat's'Compem- ENERGY PEE
7i sedan hawser California.Date WAI'FIR HEATER W/VENTIELF.CR
z Applicant GRADING FEE
NOTICETOAPPLICANT:It,after making this Certificate of Exemptlon,you should WA'I'His SYSTEMOREATING SOILS FEE
H become sidecar to the Worker,Campenerion pon,mo ns.1'thc Talbot Cod youms e -
WI Ih ith eoreply with such provision,or this pannitehull be dccmed revoked. WATER SERVICE
U Q CONSTRUCTION LENDING AGENCY • NEW RESIDENTIAL PLMB. SQ,Pr. PAID
I hereby nffam that there is a consmction lending agency ror the performance of no Receipt#
the work for which this prrmit is o,ucd(See 3097,Ca,C) T(YI'A
O U Lender's Nano
Lenders Address 'TOTAL:
I37BUILDING FEE1 realitythat
comply
lpan' T d tt that In,'b 'demarcations
l0.10torr t I s t o,naly -nhalIcity tr d county unficances anti state I T g m QTY. MECHANICAL PERMIT PEE
UZ building constrictive,vd hereby author'ec p_:e+na0'es of this city to enter upon the SEISMIC I'1;1:
air fermi ned,nmo ty ror inspection pro,us. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indicatory and keep harmless the City ofCupertion against
Iiabilases,judgerents costs and expenses which may In any way awmcagmins said City ALTER OR ADD TO MECH.
PLUMBING PEG
11,conscaltuance of[lie granting of us permit.
- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR IIANDIJNC ON['I'll 010,(11X1 CTM) MECHANICAL PL'G
SOURCE F,GULA 10 : I ,
2 AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCI'[ON'TAX
Signa ren ApFl,Zam ovImtor Uat EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MAT' $DISCLOSURE
Will the digh, ilirfurore baildingaceupuntsromher handle harrohms material HEATING UN IT(TO 100,00014 FIB
,,defined by the CupeNno Municipal Code,Chapter 9.12,and the Ilcalth and Surety - -
Code,Section 25532(a)R - HEATING U N IT(OVER 100.000 BTU)
Yes ❑No - VHNTILATION I-AN(SINGLE RESID) PAID
Data Reedpt#
cell the uppliumt nr future banding ecrepunt use ecimpmenl e,devices which BOILIM-COMP(3HE OR 100.000 IT
,it haznNous air ,amwatimmrs as defined by the Bay Area Air Quality Mapagemem TOTAL'
BOILER-COME(OVER 100,000 B'TU)
❑Yes E]No - -
I AIRCONDITIONER ISSUANCE DATE
1 have rend 1M1c I....Ideas mmeruds myuircnsnu matter chapter 6.95 of the Call)- .
forma Hmlth&Safety Cade,Sc ions 25505,25533 and 25534.1 understand the irtM1c NEW RESIDENTIAL MECH. SQ.R.
- itdingdows tint came ii has tar, that It G an,resporcmiity an notify the oruupmn
els wNiuhn t no issuance arnieate or Occupancy.
46
(len ror authorized ahem Mute TOTAL: ISSUED IT
OFFICE
Inspection Query for a Specfic Permit 3/31/98
• A'AAMTMOMP I$17F94M R,MIT I Q, 1.1111101NO" 115911k,0110(408W
S1274 1 IRESULTS IFRAME-R 3/12/98 3/12/98
S1274 1 RESULTS ELECT-R 3/12/98 3/12/98
S1274 1 RESULTS PLBG-R 3/12/98 3/12/98
S1274 1 RESULTS PLBG-R 3/13/98 3/13/98
S1274 1 RESULTS FRAME-R 3/13/98 3/13/98
S1274 1 RESULTS ELECT-R 3/13/98 3/13/98
S1274 I RESULTS SHTRK SCREW 3/18/98 3/18/981
IRE -1
S1274 1 SULTS SHTRK NAIL 3/19/98� /19/981
•
Pagel
Inspection Query for a Speck Permit 3/31/98
• In'�,,��t�i_GFi`(fs Ra'"ssifyall ,Cotle
CC 2F
CC 2F
CC 2F
CC 1P
CC 2P
CC 1P
CC 3P P
CC 2P
Page 2